Reassessing the approach to informed consent: The case of unrelated hematopoietic stem cell transplantation in adult thalassemia patients

Introduction: The informed consent process is the legal embodiment of the fundamental right of the individual to make decisions affecting his or her health., and the patient's permission is a crucial form of respect of freedom and dignity, it becomes extremely important to enhance the patient's understanding and recall of the information given by the physician. This statement acquires additional weight when the medical treatment proposed can potentially be detrimental or even fatal. This is the case of thalassemia patients pertaining to class 3 of the Pesaro classification where Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment. Unfortunately, this kind of intervention is burdened by an elevated transplantation-related mortality risk (TRM: all deaths considered related to transplantation), equal to 30% according to published reports. In thalassemia, the role of the patient in the informed consent process leading up to HSCT has not been fully investigated. This study investigated the hypothesis that information provided by physicians in the medical scenario of HSCT is not fully understood by patients and that misunderstanding and communication biases may affect the clinical decision-making process.Methods: A questionnaire was either mailed or given personally to 25 patients. A second questionnaire was administered to the 12 physicians attending the patients enrolled in this study. Descriptive statistics were used to evaluate the communication factors.Results: The results pointed out the difference between the risks communicated by physicians and the risks perceived by patients. Besides the study highlighted the mortality risk considered to be acceptable by patients and that considered to be acceptable by physicians.Conclusions: Several solutions have been suggested to reduce the gap between communicated and perceived data. A multi-disciplinary approach may possibly help to attenuate some aspects of communication bias. Several tools have also been proposed to fill or to attenuate the gap between communicated and perceived data. But the most important tool is the ability of the physician to comprehend the right place of conscious consent in the relationship with the patient

[Effect of hospital policies on patient mobility: Siennese experience]. Programmazione ospedaliera e flussi di pazienti: esperienza senese

The Italian National Health Service (S.S.N.), adopted in 1978 (Law n 833) and based on Beveridge's model, emphasises the citizens freedom to choose and the equal opportunity in accessing health care structures. Local Health Authorities--L.H.A. (U.S.L.--Unità Sanitarie Locali) become owners of almost all the structures in their territories and directly responsible for the satisfaction of all residents health needs. The former hospitals' network, based on independent first, second and third level public hospitals, in potential competition, was dismantled. Hospitals' financing, the main economic role of the S.S.N., was based on the documented running expenses: therefore the hospital interest to attract patients diminished and expenses increased in a uncontrolled way. In 1992, the Italian Government, (re)introduced (Law n 502) the quasi-market administered competition between Italian hospitals, making the major ones independent (Aziende Ospedaliere--A.O.) from the L.H.A. Hospital income from then is based on DRGs; the L.H.A. (and hospitals) leadership is now entrusted to managers and not politicians. We describe now how these changes were experienced by our hospital (A.O. Senese), placed in Southern Tuscany, Italy. We elaborated hospitalisation data regarding residents in the province of Siena (252,000 inhabitants) and activity data regarding its main hospital (A.O. Senese, 1200 beds, 47,000 admissions/year). Using the Gandy's Nomogram, we show the variation of patients mobility from 1988 to 1999. Our survey demonstrates that the Italian hospital system answers well enough to the legislative regulations: following the Law 833/1978 our hospital diminished its ability to attract patients from other areas; at the same time migrations of hospitals patients from Siena increased. Following the Law 502/1992, the power of attraction of our hospital is increased. Nevertheless the flow of escape continued to increase. It appears that to discourage the attraction power means to promote the loss of perceived quality and that it is difficult to correct such effects

The solvation Structure of Ca (II), Pb (II), Cd (II) in dilute aqueous solution: A first principles study

When an ion is inserted into a network of water molecules, the structure of the hydrogen bonds changes. Water is a polar molecule. It tends to orientate so to face its opposite charge to the ion. The group of water molecules bound to the ion is called “first hydration shell”. The orientation of the molecules in the hydration shell results in a net charge on the outside of this shell, a charge of the same sign as that of the ion in the center. The charge on the outside of the hydration shell tends to orient water molecules in the vicinity, leading to a second hydration shell. The purpose of this work is to conduct a systematic study of ion solvation, comparing positive ions of different size, namely the divalent Ca2+, Pb2+ and Cd2+. In particular, the analysis focuses on the characterization of the structural reorganization of the solvent due to the presence of the ion. To this aim, we use first principles calculations within the framework of the Density Functional Theory (DFT), i.e. an investigation at an electronic and atomistic scale, accounting for electronic polarization as well as geometrical conformations. A metal ion in aqueous solution (aqua-ion) is a cation, dissolved in water, of chemical formula [M(H2O)n]z+. The n water molecules directly bonded to the metal ion are meant to belong to the first coordination sphere. The sistems considered are small clusters, from one water molecule to the cluster containing a number of molecules equal to the coordination number. This stepwise analysis allows for an accurate detection of the structural and energy changes due to each additional water in the first hydration shell. There are many experimental and theoretical reports on the hydration of ions. More specifically, calcium raises great interest due to its role in many biological fuctions, several industrial applications (paper, rubber, plastics, paint production, and the wide occurrence in works of art)

Appropriatezza dei ricoveri in ospedali italiani del centro-nord

Suppl.2 - Atti 38° Congr. naz. S.It.I